DraftCapital BluecrossPolicy MP 9.015

Lung and lobar lung transplant

Clinical coverage policy for lung and lobar lung transplantation, including retransplantation, governing Capital BlueCross members and applied to specified products. Covers candidate selection, contraindications, and coding guidance where transplantation is medically necessary.

Policy Summary

PayerCapital Bluecross

PolicyLung and lobar lung transplant

Policy CodePolicy MP 9.015

Change TypeNo material change

Effective DateOct 1, 2025

Next Review Date

Key ActionObtain prior authorization and document that the candidate meets UNOS Lung Allocation Score criteria and has end-stage pulmonary disease unresponsive to maximal medical therapy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2,692lung transplants performed in the U.S. in 2022

42,880total transplants in the U.S. in 2022

21% / 40%patients reporting ≥1 malignancy at 5 and 10 years post-transplant

~30+ICD-10 diagnosis codes listed

VIII

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HistoryPolicy history notes

Coverage Criteria for Lung and Lobar Lung Transplant

inv-01: Initial transplant coverage

Covered when ALL of the following are met:

Primary coverage criteria: Individual has irreversible, progressively disabling, end-stage pulmonary disease unresponsive to maximal medical therapy; transplantation is performed at an appropriate transplant center and meets UNOS guidance (including Lung Allocation Score considerations); outcomes data support meaningful improvement in net health outcome for appropriately selected patients.

Supported by registry and case series evidence showing survival benefit (see Summary of Evidence).

inv-02: Lobar transplant coverage

Covered when ALL of the following are met for lobar transplant:

Lobar transplant criteria: Candidate has end-stage pulmonary disease and is an appropriate candidate for lobar transplant (living or deceased donor lobe) when whole-lung transplant is not feasible; selection follows the same overall criteria as whole-lung transplant.

Evidence from case series and systematic reviews supports lobar transplant in selected patients (see Summary of Evidence).

inv-03: Retransplantation

Covered when ALL of the following are met for retransplantation:

Retransplant criteria: Patient with prior lung or lobar transplant meets criteria for initial lung transplant and is evaluated appropriately; retransplantation is considered medically necessary for candidates who meet transplant criteria.

Registry and case series report favorable outcomes for retransplant in appropriately selected patients (see Summary of Evidence).

inv-04: Covered indications

Covered when medically necessary for members with one of the following diagnoses

Listed ICD-10 diagnoses: Presence of any ICD-10 diagnosis listed in the policy (including pulmonary embolism variants, pulmonary hypertension, emphysema/COPD, bronchiectasis, pulmonary fibrosis/ILD, lymphangioleiomyomatosis, Fontan-associated conditions, cystic fibrosis-related diagnoses, bronchopulmonary dysplasia, congenital bronchiectasis, and other enumerated pulmonary diagnoses) supports coverage when medically necessary.

Exact codes are enumerated in the policy code lists (chunks 18-19).

Lung or lobar lung transplantation is considered investigational for indications that do not meet the specific coverage criteria listed in this policy. Coverage is limited to situations where the candidate meets the stated requirements for medically necessary transplant (e.g., irreversible, end-stage pulmonary disease unresponsive to maximal medical therapy, appropriate transplant center evaluation, and UNOS guidance); procedures performed outside those parameters are investigational due to insufficient evidence of net health benefit.

This policy excerpt does not include a separate list of explicit clinical exclusions beyond the stated contraindications; administrative and historical edits are noted in the policy history (including removed sections such as an indications table). Providers should refer to the current policy history and full policy document for any prior sections that were removed or revised.

Potential contraindications that may render transplantation inappropriate include known current malignancy (including metastatic cancer), untreated systemic infection that would make immunosuppression unsafe (including chronic infections), and recent malignancy with high risk of recurrence. Additional considerations include systemic diseases likely to be worsened by immunosuppression, prior history of cancer with moderate recurrence risk, psychosocial or chemical dependency issues that impair adherence, significant coronary artery disease not amenable to revascularization or associated with marked left ventricular dysfunction, and colonization with highly resistant or highly virulent organisms.

Within the provided document segment there are no discrete statements labeled as 'not medically necessary' beyond the investigational stance for procedures performed outside the stated criteria and the contraindications described elsewhere in the policy.

Coding and Diagnosis Guidance

Covered CPT/HCPCS codesmixedCovered

32850	Procedure code listed as covered when medically necessary
32851	Procedure code listed as covered when medically necessary
32852	Procedure code listed as covered when medically necessary
32853	Procedure code listed as covered when medically necessary
32854	Procedure code listed as covered when medically necessary
32855	Procedure code listed as covered when medically necessary
32856	Procedure code listed as covered when medically necessary
S2061	Procedure code listed as covered when medically necessary

Example covered ICD-10 diagnoses (partial list)ICD-10Covered

C96.6	Unifocal Langerhans-cell histiocytosis
D86.0	Sarcoidosis of lung
E84.0	Cystic fibrosis with pulmonary manifestations
E88.01	Alpha-1-antitrypsin deficiency
I26.01	Septic pulmonary embolism with acute cor pulmonale

Covered ICD-10 Codes - pulmonary embolism, pulmonary hypertension, emphysema/COPDICD-10Covered

I26.92	Saddle embolus of pulmonary artery without acute cor pulmonale
I26.93	Single subsegmental thrombotic pulmonary embolism without acute cor pulmonale
I26.94	Multiple subsegmental thrombotic pulmonary emboli without acute cor pulmonale
I26.95	Cement embolism of pulmonary artery without acute cor pulmonale
I26.96	Fat embolism of pulmonary artery without acute cor pulmonale
I26.99	Other pulmonary embolism without acute cor pulmonale
I27.0	Primary pulmonary hypertension
I27.2	Other secondary pulmonary hypertension
I27.21	Pulmonary hypertension due to left heart disease (code listed)
I27.22	Pulmonary hypertension due to left heart disease

1–10 of 25

1/3

Covered ICD-10 Codes - bronchiectasis, pulmonary fibrosis/ILD, other lung diseasesICD-10Covered

J47.0	Bronchiectasis with acute lower respiratory infection
J47.1	Bronchiectasis with (acute) exacerbation
J84.10	Pulmonary fibrosis, unspecified
J84.112	Idiopathic pulmonary fibrosis
J84.170	Interstitial lung disease with progressive fibrotic phenotype in diseases classified elsewhere
J84.178	Other interstitial pulmonary diseases with fibrosis in diseases classified elsewhere
J84.81	Lymphangioleiomyomatosis
J98.2	Interstitial emphysema
J98.3	Compensatory emphysema
M34.81	Systemic sclerosis with lung involvement

1–10 of 12

1/2

Lung Allocation Score (LAS) — waitlist requirement

Requirement for waitlist rankingLung Allocation Score (LAS) must be greater than 0 for inclusion in adult waitlist ranking (children <12 receive pediatric priority).

Age-based allocation notePotential recipients ≥12 years are ranked by LAS; children younger than 12 receive pediatric priority and different priority categories.

LAS range and componentsLAS ranges from 0 to 100 and incorporates predicted survival on the waiting list and after transplantation, plus disease and clinical parameters.

Policy history and code effective dates

Recent code additions (effective 10/01/2024)Administrative update added new ICD-10 codes (e.g., I26.03, I26.04, I26.95, I26.96) with codes effective from 10/01/2024.

Provider Actions and Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for all lung and lobar lung transplant procedures. Requests must document that the member meets transplant criteria and that the procedure is coordinated with a UNOS‑listed transplant center.

Applies to single, bilateral, lobar, living-donor, and retransplant procedures
Authorization must be obtained before scheduling the transplant

Prior Authorization

Prior Authorization Conditioned on Listed Diagnoses

Coverage is conditioned on the presence of one of the listed ICD‑10 diagnoses indicating end‑stage, irreversible, progressively disabling pulmonary disease that is unresponsive to maximal medical therapy.

See policy ICD‑10 list (includes but is not limited to: J84.112, J84.170, J84.178, J43.*, J44.*, J47.*, I26.* where applicable)
Member must meet UNOS/Lung Allocation Score (LAS) and transplant center criteria

Candidate Selection, Waitlist and Ranking

inv-28: Waitlist and ranking

Candidate selection and waitlist ranking follow UNOS/OPTN allocation rules and clinical prioritization:

Age and ranking: Potential recipients aged 12 years and older are ranked using the Lung Allocation Score (LAS, range 0–100); children younger than 12 receive pediatric priority as defined by OPTN/UNOS.LAS > 0 required for inclusion on waitlist ranking

A lung review board may adjust scores on appeal and geography/blood type also influence allocation.

Clinical eligibility for waitlist: Candidates must have end-stage lung disease unresponsive to maximal medical therapy and meet UNOS/OPTN guidance for transplant candidacy.

Documentation of prior maximal medical therapy and transplant center evaluation expected.

inv-29: Candidate selection guidance

Provider evaluation and candidate selection should align with established transplant guidance and registry data:

Contraindications to Transplant

Contraindications that commonly preclude transplant candidacy include known current malignancy (including metastatic disease) and untreated systemic infection that would make lifelong immunosuppression unsafe. Other contraindications cited in the policy include recent malignancy with high recurrence risk, systemic disease likely to be exacerbated by immunosuppression, significant coronary artery disease not amenable to intervention or with severe left ventricular impairment, colonization with highly resistant or virulent pathogens, and psychosocial or substance-use conditions that impair adherence to post‑transplant care.

Pre-transplant Evaluation Requirements

Prior Authorization

UNOS/OPTN evaluation and infectious disease screening required

Candidates must undergo evaluation consistent with UNOS/OPTN guidance, including infectious disease screening (HIV, HBV, HCV) and comprehensive transplant center assessment as part of the listing process.

Refer to OPTN/UNOS allocation and public health testing guidance cited in the References for specific screening requirements.

Documentation Required

Center assessment must document prior therapies and infection risks

Transplant center evaluation must assess prior maximal medical therapy, suitability for single/double/lobar transplant, and consider organism-specific risks (e.g., Burkholderia species) that may affect candidacy.

Document prior therapies and any organism colonization or infections that influence posttransplant outcomes.

Transplant Center Requirements

Note

Transplant center responsibility and implied accreditation expectations

Transplant center clinical judgment applies for contraindications and candidate evaluation; centers are expected to follow UNOS/OPTN allocation and evaluation guidance and typically operate with appropriate accreditation (e.g., FACT) though explicit accreditation requirements are not listed in this excerpt.

Centers must apply clinical judgment regarding listed contraindications (e.g., current malignancy, untreated infection).
No explicit center volume or accreditation mandate is specified in the policy text provided.

Post-Transplant Follow-up and Long-Term Management

Long-term follow-up and management of immunosuppression and complications

Post-transplant malignancy riskMalignancies are common after lung transplantation: 21% of patients report ≥1 malignancy by 5 years and 40% by 10 years post-transplant; skin cancer and lymphoproliferative disorders are notable.

Lifelong follow-up and managementRecipients require lifelong immunosuppression and ongoing management of complications; posttransplant care is long-term and continuous.

Evidence base for long-term outcomesRegistry studies and case series inform long-term outcomes and support the need for ongoing monitoring of survival and complications.

Post-transplant follow-up and monitoring (general)

Follow recommended guidelinesPost-transplant follow-up and monitoring practices should follow cited guidelines and registry reports (e.g., OPTN/ISHLT guidance and ISHLT registry reports).

Background

Lung transplantation is a treatment option for selected patients with irreversible, end-stage pulmonary disease that is unresponsive to maximal medical therapy. For appropriately selected candidates, including some who are eligible for lobar transplants when whole-organ transplantation is not feasible, transplantation can be lifesaving or improve quality of life. Recipients require lifelong immunosuppression, and candidate prioritization for allocation uses the Lung Allocation Score (LAS) (candidates ≥12 years are ranked by LAS; LAS must be > 0 for waitlist ranking). Lobar lung transplant (living or deceased donor lobes) and retransplantation are considered under the same overall selection principles when criteria are met.

Definitions

END-STAGE — definition

DefinitionEND-STAGE: the final phase of a disease process.

Context of useUsed to describe irreversible, progressively disabling disease states that may qualify for transplant consideration when unresponsive to maximal medical therapy.

Policy implicationRequests must document end-stage status to support medical necessity for transplantation.

LOBE — definition

DefinitionLOBE: a well-defined part of an organ separated by boundaries.

Clinical applicationRefers to lobar lung transplantation (living or deceased donor lobes) as an alternative when whole-lung transplant is not feasible.

Policy Revision History

2025-09-12administrative_updateLatest

Removed Benefit Variations section and updated Disclaimer.

2025-09-03administrative_update

Added new ICD-10 codes (administrative update).

2024-10-01code_effective_date

Policy Summary

PayerCapital Bluecross

PolicyLung and lobar lung transplant

Policy CodePolicy MP 9.015

Change TypeNo material change

Effective DateOct 1, 2025

Next Review Date

Key ActionObtain prior authorization and document that the candidate meets UNOS Lung Allocation Score criteria and has end-stage pulmonary disease unresponsive to maximal medical therapy.

SourceLink

On This Page

Administrative updates through 09/03/2025Policy history includes administrative updates adding ICD-10 codes and other edits through 09/03/2025 (entries list multiple 2024–2025 updates).

Earlier history entriesPolicy history records prior consensus and administrative reviews (02/11/2020, 05/03/2021, 12/08/2022, 08/29/2023, 08/20/2024) noting code additions and reference updates.

Documentation Required

Pre‑transplant Therapy Requirements

Members must have undergone maximal medical therapy and, where appropriate, prior surgical options before transplant referral. Documentation should show failure of optimized medical management and any relevant prior surgical interventions.

Maximal medical therapy examples: optimized inhaled therapies, pulmonary rehabilitation, oxygen supplementation, treatment of infections, targeted therapies for underlying disease
Prior surgical options where applicable: lung volume reduction surgery for COPD, other disease‑specific procedures

Step Therapy

No formal step‑therapy sequence is required by this policy; there are no mandated trials of alternative transplant types prior to authorization beyond demonstration of maximal medical/surgical management.

Step therapy does not apply to indication for lung or lobar transplant
Authorization focuses on documentation of disease severity, prior therapies, and transplant center criteria

Documentation Required

Required Documentation

Documentation submitted with authorization requests must support end‑stage irreversible disease, failure of maximal medical therapy, and meet UNOS/transplant center selection criteria. Include clinical notes, imaging, pulmonary function tests, oxygen requirements, LAS if applicable, and evidence of psychosocial evaluation and transplant center acceptance.

Required documents: clinical summary, PFTs, 6‑minute walk or exercise testing, imaging reports, infectious disease testing, listing decision from transplant center
Documentation must address contraindications (e.g., active malignancy, uncontrolled infection, severe comorbidity, inability to adhere to therapy)

Billing Rule

Coding and Administrative Alignment Risk

Coding and administrative updates may affect coverage determinations. Ensure current ICD‑10 codes and any policy administrative updates are used when submitting authorization and claims to avoid denials.

Use the ICD‑10 codes current to the service date (policy has had multiple administrative updates adding/renaming codes; latest effective date 10/01/2024 and administrative updates through 09/12/2025)
Verify claim coding aligns with the authorization request and transplant center documentation

Note

Supporting References and Guideline Documentation

Authorization requests and clinical decision‑making should reference established guidelines and evidence. Relevant resources include OPTN/UNOS allocation policies, ISHLT registries and guidelines, ATS/ERS statements, and specialty society guidance (e.g., Cystic Fibrosis Foundation) and peer‑reviewed literature.

OPTN/UNOS allocation and listing criteria
ISHLT registry reports on indications and outcomes
Public Health Service guidance for infection testing in transplant candidates

Denial Risk

Denial Triggers

Authorization may be denied if required documentation is missing, if listed contraindications are present and unaddressed, or if the member does not meet UNOS/transplant center criteria. Administrative denials can occur when coding does not match the authorized indication or when policy/version mismatches exist.

Denial triggers: absent or insufficient clinical documentation, active contraindications (e.g., untreated malignancy, uncontrolled infection), failure to document maximal therapy
Administrative denial triggers: obsolete or incorrect ICD‑10 coding, missing transplant center acceptance, mismatch between authorization and claim

Guideline alignment: Evaluation and selection should follow referenced guidelines and registry reports (e.g., ISHLT selection consensus, OPTN allocation policy, Cystic Fibrosis Foundation referral guidance, ATS/ERS/ILD guidelines) to inform candidacy and expected outcomes.

References cited in the policy provide detailed criteria and outcome data but specific stepwise elements are found in the cited sources.

Documentation Required

Follow cited guidelines for comprehensive evaluation

The comprehensive prelisting evaluation should follow cited consensus and guideline documents (ISHLT selection consensus, OPTN allocation policies, and public health testing guidance) referenced in the policy's References section.

Use the policy's References (ISHLT, OPTN, ATS/ERS, CF Foundation) to guide the evaluation checklist and documentation.

Documentation Required

Document LAS and waitlist ranking details

Evaluation specifics (age-appropriate LAS consideration, ranking, and transplant review board authority) must be documented per policy: candidates ≥12 years are ranked by LAS (score 0–100) and LAS must be > 0 for listing.

Document LAS value and any adjustments or appeals by the lung review board when applicable.

Documentation and reportingProviders should align monitoring with referenced literature and registry data to support clinical decisions and documentation.

No specific duration limits in policy excerptThe policy notes adherence to guideline-recommended monitoring but does not specify exact coverage durations or specific monitoring intervals in this excerpt.

Lobar transplant selection follows the same overall criteria as whole-lung transplant per the policy summary and evidence sections.

Regulatory status — solid organ transplantation

Regulatory noteSolid organ transplantation is a surgical procedure and is not regulated by the U.S. Food and Drug Administration.

FDA-regulated componentsThe FDA regulates human cells and tissues intended for implantation, transplantation, or infusion under 21 CFR parts 1270 and 1271.

Implication for organsSolid organs used for transplants are subject to the human cells and tissues regulations described in 21 CFR 1270 and 1271.

Covered diagnoses — selected pulmonary ICD-10 codes

Pulmonary embolism and thrombotic emboliI26.92–I26.99 and related I26 series (e.g., I26.93, I26.94, I26.95, I26.96) are listed as covered when medically necessary for pulmonary embolism variants.

Pulmonary hypertensionI27.x series (e.g., I27.0 primary pulmonary hypertension; I27.2 other secondary pulmonary hypertension; I27.24 chronic thromboembolic pulmonary hypertension; Fontan-associated codes I27.840–I27.849) are included.

Emphysema/COPD and chronic bronchitisJ42, J43.x (unilateral, panlobular, centrilobular emphysema), and J44.x (COPD with infection or exacerbation) are listed as covered diagnoses.

Bronchiectasis and interstitial lung diseaseJ47.x (bronchiectasis), J84.10, J84.112, J84.170, J84.178, J84.81 and related ILD/fibrosis codes are enumerated as covered when medically necessary.

Other specified lung conditionsAdditional covered diagnoses include lymphangioleiomyomatosis (J84.81), bronchopulmonary dysplasia (P27.1), congenital bronchiectasis (Q33.4), and systemic sclerosis with lung involvement (M34.81).

Multiple ICD-10 code additions became effective (I26.03, I26.04, I26.95, I26.96) and descriptions for I26.93 and I26.94 were revised (administrative update dated 08/16/2024).

2024-08-20consensus_review

Consensus review: no changes to policy statements; references reviewed and updated; no coding changes noted.

2023-08-29consensus_review

Consensus review: no change to policy statement; background updated and references reviewed; no coding changes.

2022-12-08minor_review

Minor review: deleted the indications table from the policy statement.

2021-05-03consensus_review

Consensus review: no change to policy statement; references updated; description/background revised and ICD-10 codes I27.0 and J84.170 were added; J84.17 removed.

2020-09-01administrative_update

Administrative update: added ICD-10 J84.178 (noted twice in history).

2020-02-11consensus_review

Consensus review: references and coding reviewed with no changes to policy statements.